Nokea
Which of the following is a discharge criterion from the PACU for a patient following surgery?
- A. Oxygen saturation above 90%
- B. IV narcotics given less than 15 minutes ago
- C. Oxygen saturation below 90%
- D. IV narcotics given less than 30 minutes ago
Correct Answer: A
Rationale: Oxygen saturation above 90% is a discharge criterion from the PACU (Post-Anesthesia Care Unit) for a patient following surgery. This indicates that the patient is effectively exchanging oxygen and carbon dioxide, which is essential for proper respiratory function. Adequate oxygenation is crucial for the patient to be safely discharged from the PACU and transitioned to a regular hospital room or home. Monitoring oxygen saturation helps ensure that the patient's respiratory status is stable before leaving the PACU. If a patient's oxygen saturation is below 90%, further assessment and interventions may be necessary before discharge is considered.
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Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
- A. Wilma places 2 fingers between the tie and neck
- B. The tracheotomy can be pulled slightly away from the neck
- C. James' neck veins are not engorged
- D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process
Correct Answer: A
Rationale: Placing 2 fingers between the tracheostomy tie and the neck is a reliable method to ensure that the tie is not too tight. This technique allows for proper circulation around the neck area and helps prevent skin irritation or pressure ulcers from developing. It strikes a balance between securing the tracheostomy in place and maintaining the patient's comfort and safety. Checking for appropriate tightness by using the finger method is a standard practice in tracheostomy care to prevent complications related to excessive pressure or constriction.
Which food choice contains the highest kilocalorie?
- A. Apple
- B. Chicken
- C. Bacon
- D. Bread
Correct Answer: C
Rationale: Bacon contains the highest kilocalories among the food choices provided. Bacon is high in fat, with approximately 42 kilocalories per slice (8 grams) compared to other options like an apple (52 kilocalories), chicken (231 kilocalories), and bread (79 kilocalories). The high fat content in bacon contributes to its higher caloric value compared to the other choices listed. As such, bacon is the food choice with the highest kilocalorie content in this selection.
Parents tell the nurse that their 1-year-old son often sleeps with them. They seem unconcerned about this. The nurse's response should be based on which statement?
- A. Children should not sleep with their parents.
- B. Separation from parents should be completed by this age.
- C. Daytime attention should be increased.
- D. This is a common and accepted practice, especially in some cultural groups.
Correct Answer: D
Rationale: The correct response is D because it acknowledges that co-sleeping with children, especially infants and toddlers, is a common and accepted practice in various cultural groups. Co-sleeping can have benefits such as promoting bonding and facilitating breastfeeding. However, it is essential for the nurse to educate the parents on safe sleep practices to reduce the risk of Sudden Infant Death Syndrome (SIDS) or other sleep-related accidents. It is important to provide guidance on creating a safe sleep environment for the child if they continue co-sleeping.
When palpating the brachial, radial, and femoral pulses of a neonate, the nurse notes a difference in pulse amplitude between the femoral and radial pulses bilaterally. This difference suggests:
- A. Patent ductus arteriosus
- B. Coarctation of the aorta
- C. Diminished cardiac output
- D. Left to right shunting in the heart. 104 Practice Exam I
Correct Answer: B
Rationale: Coarctation of the aorta is a congenital heart defect in which there is a narrowing of the aorta leading to differential pulses in the upper and lower extremities. In neonates, this can manifest as weaker femoral pulses compared to radial pulses due to decreased blood flow to the lower body. This difference in pulse amplitude between the femoral and radial pulses bilaterally is a classic finding in coarctation of the aorta, making it the most likely cause in this scenario. Other conditions like patent ductus arteriosus, diminished cardiac output, or left to right shunting in the heart may not specifically present with this particular pulse amplitude difference.
The laboratory results of a patient with disseminated intravascular coagulation are likely to include:
- A. decreased levels of fibrin split products.
- B. increased levels of fibrinogen.
- C. increased platelet counts.
- D. prolonged prothrombin and partial thromboplastin times.
Correct Answer: D
Rationale: DIC leads to prolonged clotting times due to consumption of clotting factors and platelets.